Part 2 below is our interview with Canberra-based ICU Nurse Educator Rachel Longhurst, who provides a unique perspective on the characteristics of a great ICU nurse, and shares her advice for anyone considering a career in the critical care environment.

Describe the ICU environment/atmosphere – why do you love it?

The ICU environment varies depending on where you work, whether it’s on open unit, with beds divided by curtains, or a more segmented unit with single rooms that can be closed off by doors. The latter can actually be quite deceiving because a lot can go on behind those closed doors. It also depends on how busy it is, who’s working, what time of day it is, what the patient cohort is, what family members are in the unit, whether there are any particular cultural activities being undertaken, or whether there are unexpected activities going on (ie patient deteriorations, procedures or resus). Sometimes it can be calm and quiet (and when we utter those words it almost invariably sees chaos erupt), other times it’s intensely busy with lots of high acuity patients.

I think the things that I love about ICU nursing are the strictly ratio-ed care and support structures that we are mandated to have in place, the quality we strive for through systematic care processes, the autonomy ICU nurses have in managing their patients and the expectation of critical thinking and higher-level clinical reasoning.

I admit, I always loved the adrenaline rush of working under the pump, a race against time to stabilise someone, to bring them back from the edge of deterioration they were teetering on. In saying that though, I equally love the palliative care element that occurs in the ICU (yes 5-10% of what we do is palliative care); the facilitated change in trajectory from the hope of survival to the hope of a peaceful death. When we get this right, it can make a huge difference for a patient and their family.

What characteristics make a great ICU nurse?

So many things go into making a ‘good’ ICU nurse and it really depends on what stage of their career a nurse is at as to what qualities they need to bring to the job. When we look to bring in nurses new to critical care, we don’t expect them to have all the necessary skills (we teach them those), but we look for people with a desire to continue to learn, people who are receptive to feedback, people who demonstrate capacity for recognising deterioration, possess critical thinking ability and use reflection, and who demonstrate resilience capacity with well-established coping strategies.  

A ‘good’ experienced critical care nurse needs to have the above, but also requires intuition, clinical proficiency and troubleshooting, must have an holistic approach to care, and be able advocate for patients and families. Equally, they need good leadership skills inclusive of a willingness to role model and grow others, openness to change, and be life-long learners. If they can manage that with high levels of emotional intelligence, then you pretty much have the perfect nurse!

Should nurses consolidate within non-critical care environments prior to starting ICU? And which clinical areas are the best ones to prepare nurses who want to work in ICU?

This is a hotly debated question in ICU’s around the country I’m sure. There are pros and cons for each approach. However, our transitional program mandates that staff must have a minimum of one year’s acute registered nursing experience prior to applying for the program. My thinking with that is that it allows a transition to practice culture shock to occur externally, rather than at the same time as the culture shock of transitioning to ICU. Plus it allows for general nursing foundation skills to be embedded, before immersing people into an ICU nursing environment.

I don’t necessarily have a preference for which clinical areas people do their time in beforehand. In my experience they all have benefits as ICU patients may arrive from all around the hospital. We have had staff transition from the ED, CCU, OT, medical and surgical wards, palliative care and even one midwife (who was also an RN). Every single one of them brings skills and experiences from those other area that are useful. All our staff will be supported through specific learning they will go through during our ICU transition program.

Wherever you are, learn as much as you can and invest time into learning skills that will set you up for ICU.

This might be understanding ECGs, using hi-flow oxygen therapy, getting a central line competency, attending deteriorating patient education and learning assessment skills.

When you interview for your ICU transition program or other roles what are you looking for? How do you choose a candidate?

What I am most interested in when people apply for our transition program is how teachable they are. Do they possess skills in cognition and metacognition? Can they critically think? Do they reflect on practice? Do they demonstrate self-motivated learning? Are they receptive to feedback? Can they take feedback and alter their practice? In other nursing roles I am looking for people who are committed to ongoing professional development of self and others, are able to advocate for patient safety, and whose values align with promoting positive culture.

What are the biggest challenges you find new ICU nurses face or struggle with?

There is an element of transition shock that occurs when coming into the ICU environment. New nurses often struggle with time management and prioritisation. One of the big things for new ICU nurses is that they spend large amounts of time in a space of analytical reasoning (our more proficient and expert nurses spend large amounts of time doing things intuitively, making things look really easy). This analytical reasoning is very time consuming and slows them down. In addition to this, they are trying to learn a new environment, new processes, as well as manage the learning related to the program and their patients. It can be very exhausting.

On top of this, there is a component of stress and emotional drain by the things that we can see and do in the ICU space. We know that all our staff can be impacted significantly by things that ‘go wrong’, by resuscitations, organ donations and other end of life scenarios – but our junior staff, often seeing and participating in these things for the first time can really suffer from an elevated level of distress related to these things.

We try to provide a highly supported program for new staff in the unit, but despite that, I tell my new transition recruits that somewhere between week 8 and week 12 of the program they should expect to find themselves in my office with the tissue box, questioning whether they’ve made the right decision in coming to the unit. The good news is 98% of them come out the other side and never look back.

What advice do you have for nurses to deal with the crashing patient?

My instinct is to tell you that a little bit of calm goes a long way. But that’s not great advice to junior staff, as it’s actually very hard to overcome the flight or fight response from your own adrenaline to get to that state and can take years of practice. So perhaps a better piece of advice is, when you’re worried, when your patient is crashing, call for help early and have the support from senior clinicians around you.

What are the ingredients of a ‘good’ resus compared to a ‘bad one’?

Ah ‘good’ resuscitations… there are so many answers to that question. A good resuscitation is one we don’t have to do because we’ve had the appropriate discussions with patients to prevent its necessity. A good resuscitation is when we quickly get a patient back without any neurological deficit. A good resuscitation is when the team functions effectively.

Often when nurses talk about ‘good resuscitations’ vs ‘bad resuscitations’ it’s about how felt about the resuscitation in relation to one of two things. Firstly, a ‘bad’ resuscitation can be one we didn’t see coming in a patient that on the balance of averages shouldn’t be arresting (this makes us feel like we’ve failed in a sense), and secondly, ‘bad’ resuscitations can refer to a failure in crisis resource management somewhere, for example, failure to escalate or bring inappropriate resources, poor leadership, communication challenges, poor decision making or decision paralysis, and a general lack of situational awareness. Just one of these things can unravel a resuscitation situation.

How do you deal with grief and death in the workplace? How do you de-stress after a shift and what self-care strategies do you utilise?

I am an advocate for debriefing, both formally and informally, particularly after events and incidents that are potentially distressing and traumatic such as deaths, resuscitations and donations. I like to undertake a period of reflection for anything that has caused stress or discomfort to me after my shift. I usually do this in one of two places – in the car driving home (if I don’t have to pick up the kids), or in the shower (about the only place I get peace and quiet!).

If something still troubles me after that, it’s something I would probably take to clinical supervision. In the last 12 months the Chief Nurse in the ACT has invested in training a number of clinical supervisors for reflective practice using the role development method. I was lucky enough to become a supervisor and receive that training as part of the pilot program. However, part of the training has been undertaking my own supervision, which I have found a really useful place to explore my role and response to things, to validate my feelings, and to think about how I might do things differently in the future. I have found it quite transformative.

What advice would you give your ‘junior nurse self’ if you could?

  • Transition shock is a real thing and nursing can be a tough gig. You are going to see and do things you can’t imagine right now – identify strategies for good self-care and start implementing them now!
  • Emotional intelligence may just be the most important type of intelligence you can possess.
  • You are going to learn that your view of the world is not the only view of the world – what you need to know is that’s OK. Novice nurses often talk about ‘treating others as you wish to be treated.’ We make assumptions that other people want the same things we want, and this is often not the case. Treat people as they wish to be treated – and this means asking people what they want!

What is the take away message you would like the readers to remember?

Take opportunities as they come up, or apply for opportunities as they arise. Ignore that little voice that says ‘I won’t get it, so I won’t bother.’

We are our own worst enemy sometimes. It’s that old thing where we see failure and success as opposites when in reality a few failures are actually stepping stones to success if we are prepared to grow from the experience. If you’re not successful the first time, always seek feedback. See it as an opportunity to improve yourself. People who can demonstrate that level of self insight and self-improvement are worth their weight in gold.   

For more on ICU you can check out the Australian College of Critical Care Nurses